Restraint In Intensive Care Unit Research Articles

Moral Dilemmas Regarding Physical Restraints in Intensive Care Units: Understanding Autonomy, Beneficence, Non-Maleficence and Justice in the Use of Physical Restraints.

In intensive care units, patients are often restrained to ensure their safety, with physical restraints being the most commonly used method. However, physical restraints compromises the patient's freedom, health and comfort, and nurses often face moral dilemmas when deciding whether to use physical restraints. This article examines physical restraints through the four universal principles of autonomy, beneficence, non-maleficence and justice. Through these principles, the authors will critically explore whether the physical restraints of patients by nurses is ethical in practice and what moral issues exist. This paper also explores conflicts and moral dilemmas for nurses in this context. Finally, suggestions are made on changes to education and clinical practice.

Prevalence and Influencing Factors of Physical Restraints in Intensive Care Units: A Retrospective Cohort Study.

Physical restraints are used routinely in intensive care units (ICUs) and have negative effects. It is critical to identify the impact factors of physical restraints on critically ill patients. The present study investigated the prevalence of physical restraints and impact factors associated with their use in a large cohort of critically ill patients over one year. A retrospective cohort study was performed in multiple ICUs at a tertiary hospital in China in 2019 using observational data from electronic medical records. The data consisted of demographics and clinical variables. Logistic regression was used to assess the independent impact factors for the use of physical restraint. The analysis consisted of 3776 critically ill patients with a prevalence of physical restraint use of 48.8%. The logistic regression analysis indicated that physical restraint use was associated with independent risk factors, including surgical ICU admission, pain, tracheal tube placement, and abdominal drainage tube placement. Physical restraint use was associated with independent protective factors, including male sex, light sedation, muscle strength, and ICU length of stay. The prevalence of physical restraint use in critically ill patients was high. Tracheal tubes, surgical ICU, pain, abdominal drainage tubes, light sedation, and muscle strength were independent variables associated with the use of physical restraint. These results will assist health professionals in identifying high-risk physical restraint patients based on their impact factors. Early removal of the tracheal tube and abdominal drainage tube, pain relief, light sedation, and improvements in muscle strength may help reduce the use of physical restraints.

Nurses’ Knowledge, Attitudes, and Practices towards Using Physical Restraints in Intensive Care Units

Background: With the fact that physical restraints is widely used in intensive care units, further studies are needed to set a baseline for evidence-based practice and to develop regulations. Aim: To examine Jordanian ICU nurses' knowledge, attitudes, and practices of physical restraints. Methods: A descriptive cross-sectional design was applied using online survey. A convenience sample of 145 nurses filled out the questionnaire who were registered nurses with at least one year of experience in ICU. In addition to demographic data sheet, they completed a 3-domain questionnaire; levels of knowledge, attitudes, and practices regarding using physical restraints. Results: Participants’ scored relatively low on knowledge (M= 3.3/11, SD= 1.8), moderate on attitudes (M= 29.4/48, SD= 3.8), and moderate on practices regarding physical restraint (M=23.2/42, SD= 7). Results revealed that participants’ practice of physical restraint had a positive correlation with both their knowledge and attitudes. Many significant differences were noticed based on participants’ characteristics. Conclusion: Local guidelines should be legislated to regulate nurses’ and other care providers’ PR practices to maintain patient safety and avoid legal consequences. Also, educational programs are needed to promote nurses’ knowledge and attitudes and compliance toward the acceptable guidelines regarding PR.

Critical care nurses' experiences of physical restraint in intensive care units: A qualitative systematic review and meta-synthesis.

Physical restraint is widely used in intensive care units. Critical care nurses are the primary decision makers and practitioners of physical restraint. However, little is known about the qualitative evidence of their experience of physical restraint. To aggregate, synthesise and interpret the qualitative evidence of studies that explored critical care nurses' experiences of physical restraint in intensive care units. A qualitative systematic review and meta-synthesis was conducted following Joanna Briggs Institute methodology and reported following the ENTREQ statement. Qualitative studies published in the English and Chinese were systematically searched in eight databases. PubMed, Web of Science, CINAHL, EMBASE, PsycINFO, China National Knowledge Infrastructure, Wan Fang, and Chinese Biomedical Literature Database from inception to November 2021. Two reviewers independently assessed the study eligibility and performed the data extraction and the quality appraisal. A meta-aggregative approach was used to synthesise findings. The review protocol was registered prospectively with PROSPERO (CRD42021278671). Thirteen studies were included. A total of 48 intact and definite codes were extracted and classified into ten sub-categories. Four themes were finally identified: intention, alternatives, determinants, and reflection. The intention of critical care nurses to use physical restraint is primarily driven by patient safety. Nurses will consider alternatives; however, many determinants urge nurses to implement physical restraint. Nurses prefer to sacrifice patients' comfort to ensure their safety. When nurses reflect on what they have done, some experience moral distress, but most rationalise their decision making. Further studies should explore the safety of alternatives, reduce the use of physical restraint, and pay more attention to nurses' moral distress through these insights. Developing alternatives, providing relevant training for nurses, physicians, patients, and families to facilitate a restraint-free culture, and developing high-quality guidelines and regulations are essential strategies to reduce the use of physical restraint in ICUs.

Good practices for physical restraint in intensive care units: integrative review.

to describe the available evidence on indications, complications, care and alternative strategies in the use of physical restraint in adult patients in Intensive Care Units.Methods: an integrative review conducted in the LILACS, Nursing Database, Índice Bibliográfico Español en Ciencias de la Salud, Scopus and CINAHL databases and the PubMed portal, in the period from June to August 2018. the final selection was of 19 articles, from which the indications, complications, care and alternative strategies were extracted. The studies were conducted between the years 2003 and 2018, with a predominance of the United States; they were mostly classified (58%) in level 6 evidence, being performed by nurses, with multi-professional participation of psychologists, pharmacists, physicians, and nurses. the most common practices regarding physical restriction were described, and the need for the elaboration and implementation of protocols on intervention to support decision making was observed.

Nurses' knowledge and practices of physical restraints in intensive care units: An observational study.

AimTo investigate the knowledge and practice of physical restraints (PR) among Jordanian intensive care unit (ICU) nurses.DesignA descriptive, observational design was used.MethodsA convenience sampling was used to recruit participants. We examined the knowledge of PR in 301 nurses (knowledge check) and the real‐time practice of PR in 81 nurses (direct observation) in ICU. A knowledge questionnaire was used to collect data on knowledge about PR use, and data on their practice of PR were observed and documented using an observation checklist.ResultsThe mean scores of nurses' knowledge and practices were 61.5 (SD = 12.1) and 57.4 (SD = 9.7), respectively. More than half of nurses had poor knowledge of PR use and incorrect practice of implementing PR (51.5% and 60.5%, respectively). Results indicated a positive correlation between nurses' knowledge and their use of PR.

The challenges of using physical restraint in intensive care units in Iran: A qualitative study.

Physical restraint is widely used in intensive care units to ensure patient safety, manage agitated patients, and prevent the removal of medical equipment connected to them. However, physical restraint use is a major healthcare challenge worldwide. This study aimed to explore nurses' experiences of the challenges of physical restraint use in intensive care units. This qualitative study was conducted in 2018-2019. Twenty critical care nurses were purposively recruited from the intensive care units of four hospitals in Tehran, Iran. Data were collected via in-depth semi-structured interviews, concurrently analyzed via Graneheim and Lundman's conventional content analysis approach, and managed via MAXQDA software (v. 10.0). Three main themes were identified (i) organizational barriers to effective physical restraint use (lack of quality educations for nurses about physical restraint use, lack of standard guidelines for physical restraint use, lack of standard physical restraint equipment), (ii) ignoring patients' wholeness (their health and rights), and (iii) distress over physical restraint use (emotional and mental distress, moral conflict, and inability to find an appropriate alternative for physical restraint). Critical care nurses face different organizational, ethical, and emotional challenges in using physical restraint. Healthcare managers and authorities can reduce these challenges by developing standard evidence-based guidelines, equipping hospital wards with standard equipment, implementing in-service educational programs, supervising nurses' practice, and empowering them for finding and using alternatives to physical restraint. Nurses can also reduce these challenges through careful patient assessment, using appropriate alternatives to physical restraint, and consulting with their expert colleagues.

Influence of mutual support and a culture of blame among staff in acute care units on the frequency of physical restraint use in patients undergoing mechanical ventilation.

AimReducing the use of physical restraint in intensive care units is challenging, and little is known about the influence of culture on physical restraint use in this setting. The present study aims to verify the hypothesis that mutual support and a culture of blame among staff are associated with higher physical restraint use for mechanically ventilated patients.MethodsWe undertook a survey of nurses in intensive care units caring for mechanically ventilated patients in acute care units. The perceived frequency of physical restraint, mutual support, and culture of blame were measured. We predefined a high frequency physical restraint use group and compared the institutional characteristics, human resources, mutual support, and culture of blame between this group and the others (the control).ResultsThree hundred and thirty‐three responses were analyzed. The mean number of beds per nurse was not significantly different between the groups; the mean and percentage of positive responses about mutual support and a culture of blame were significantly lower in the high frequency physical restraint use group. After adjusting variables in a multivariable regression analysis, a less positive response about the culture of blame was the only independent factor to predict high frequency physical restraint use.ConclusionThe study suggests that changing the culture of blame, rather than increasing the number of nurses, is important for reducing physical restraint use.

Analysis of a nurses’ knowledge survey on the use of physical restraint in intensive care units

ObjectivesTo determine nurses’ knowledge level regarding physical restraint use in intensive care units and its associated factors. MethodA cross-sectional multicentre study was carried out in 12 critical care units of 8 hospitals in Spain (n=354 nurses). An ‘ad-hoc’ knowledge survey was developed, and their content was validated by experts. The survey obtained a test-retest stability of ICC=.71 (95% CI: .57–.81) in a previous pilot study. A final 8-item tool was designed. Sociodemographic and professional variables from the participants were collected; as well as structural and clinical variables from the units analysed. A descriptive and association analysis between variables was performed. A p-value<.05 was deemed statistically significant. ResultsTwo hundred and fifty nurses answered the survey (70.62%). Mean age of the participants was 36.80 (SD 9.54) with 10.75 (SD 8.38) years of professional experience in critical care. Seventy-three point six percent had never received previous training about physical restraints. Knowledge mean value was 4.21 (SD 1.39) (range 0–8). Knowledge level was associated with the referral hospital (p<.001). Nurses with a higher knowledge level are more likely to work in units with informed consent sheets for physical restraint use (p<.001); flexible family visiting (p<.001); analgo-sedation protocol (p=.011), and units in which nurses had autonomy to manage analgo-sedation (p<.001). Individual sociodemographic and professional data was not associated with knowledge level. ConclusionsFurther training regarding physical restraint use is needed for critical care nurses. The work environment where nursing care is given has a great influence on nurses’ knowledge level about this intervention.

Physical restraints in intensive care units: a national questionnaire survey of physical restraint use for critically ill patients undergoing invasive mechanical ventilation in Japan.

AimsPhysical restraints are often used for patients undergoing mechanical ventilation to protect important medical equipment. However, they have adverse physical and psychological effects and could pose ethical hazards. Physical restraint use varies by country, but so far there is little understanding of the frequency of physical restraint use among intensive care unit (ICU) patients in Japan. The present study aims to describe the frequency of physical restraint use among Japanese patients undergoing mechanical ventilation. Additionally, it attempts to verify the hypothesis that insufficient human resources have increased the frequency of physical restraints.MethodsWe undertook a cross‐sectional online open anonymous survey of ICU nurses using a self‐administered questionnaire to examine the use of physical restraints for patients undergoing invasive mechanical ventilation in Japan.ResultsWe obtained 175 responses, of which 46 were excluded. Of the respondents, 43% reported that physical restraints were used for more than 75% of mechanically ventilated patients. Intensive care units with a higher frequency of physical restraint use had a significantly greater number of beds per nurse compared to those with a lower frequency; however, after adjusting for the number of beds in the ICU and hospital type in a logistic regression analysis, the number of beds per nurse was no longer significantly related to the use of physical restraints.ConclusionsPhysical restraints are commonly used among patients undergoing mechanical ventilation in Japan. A systematic approach to reducing physical restraint use among mechanically ventilated patients is needed.

Reducing Use of Restraints in Intensive Care Units: A Quality Improvement Project.

Use of physical restrainst is scrutinized in intensive care units today. Usage rates for the 5 intensive care units in the Christiana Care Health Services, Newark, Delaware, were higher than the National Database of Nursing Quality Indicators mean rate of 9.61% to 15.43% for many months during fiscal years 2013 and 2014. To reduce and sustain the restraint rates to less than the national database mean rates for all 5 intensive care units. A quality improvement process was used that included forming a multiunit restraint collaborative; reviewing restraint data, including self-extubation rates; surveying staff nurses to examine alignment with evidence-based practice; and selecting a new restraint-alternative product. All 5 intensive care units were able to successfully decrease restraint rates to less than the national database mean for the majority of the months since the start of the restraint collaborative in September 2012. Use of a restraint collaborative with subsequent adoption of restraint alternatives led to a decrease in restraint rates for the 5 intensive care units to less than the national database mean, enabled sustained success, and helped align nurses' beliefs with evidence-based practice.

Nurses' Information, Attıtude and Practices towards Use of Physical Restraint in Intensive Care Units.

Introduction: Physical restraint may seem to be a useful and simple procedure to help the treatment but is a complex practice including physical, psychological, judicial, ethical and moral issues. Research was made on description basis in order to determine the knowledge, attitude and application levels of nurses working in critical care units about physical restraint applied on patients. Methods: The study was performed as a descriptive and correlation study. Working in ICUs, 158 nurses constituted the sampling. “Levels of Knowledge, Attitudes and Practices of Staff Regarding Physical Restraints Questionnaire” was used to collect data. Results: For information, attitude and practice scores, participants’ scores were 7.1(1.7), 31.8 (4.6) and 36.6 (3.2), respectively. No association was found between information subscale, and age, professional years, working time in ICUs and weekly working hours. However, for attitude subscale, a negative and weak association was found between age (r=-0.229) and professional years (r=-0.174), and increasing these variables decreased attitude score. No association was found between attitude score, and working time in ICUs and weekly working hours. While there was no association between practice score, and age, professional years and working time in ICUs, the increase in weekly working hours (r=-0.243) was found to decrease practice score, and this association was found weak. Conclusion: In conclusion, we consider nurses’ level of information is sufficient, but attitudes and practice were not at a positive level. It is recommendable that out of such conditions, novel approaches should be developed to decrease the use of physical restraint.

Influence of physical restraint on delirium of adult patients in ICU: A nested case-control study.

To investigate the impact of physical restraint on delirium of adult patients in intensive care unit. Delirium is a common clinical syndrome in intensive care unit, correlated with various adverse clinical outcomes. Physical restraint is a precipitating factor for delirium; however, the effect of physical restraint on delirium, such as duration, number and appliance is still unclear. A nested case-control study. A cohort of 593 intensive care unit patients were observed for 12months, and 447 of them who received physical restraint were included for analysis. Delirium was assessed using the Confusion Assessment Method for the intensive care unit. During hospitalisation in intensive care unit, newly-onset delirium patients (the delirium group), and nondelirium patients of similar age, same gender, and conditions of mechanical ventilation and sedative drug usage (the nondelirium group) were included as the matching criteria. Patient data were acquired by reviewing medical and nursing electronic records. Among the 447 patients that had been physically restrained, 178 (39.8%) developed delirium. Delirium risk in patients with restraint ≥6days was 26.30 times higher than in those <6days. Patients who had two and three times of restraint had a 2.38-fold and 3.62-fold higher risk of delirium than those with one time of restraint. However, the appliance, site, time to apply and remove restraint had no effect on the incidence of delirium. The incidence of delirium is high when patients use physical restraint. Duration and number of restraint are positively related to delirium. Restrictions on the use of restraint in intensive care unit are required to reduce the occurrence of delirium. To reduce delirium risk of patients in intensive care unit, nurses need to assess the risk of physical restraint and consider alternative measures, thereby to achieve the minimisation of the use of restraint.

Knowledge, attitude and practice of intensive care unit nurses about physical restraint.

Physical restraint is mainly used in intensive care units (ICUs) to prevent delirious or agitated patients from removing tubes and lines connected to them. However, inappropriate use of physical restraint could have many detrimental physical effects on the patient, such as nerve damage, asphyxiation or even death. The aim of the study is to investigate nurses' knowledge, attitude and practice of physical restraint in ICUs in Jordanian hospitals, about which little is known. A descriptive and cross-sectional design was used. A convenience sample of 400 nurses working in three public hospitals and one university-affiliated hospital from different geographical regions in Jordan was selected. An Arabic version of the Physical Restraint Questionnaire (PRQ) was used to collect the data. A total of 300 completed questionnaires were returned, with a response rate of 75%. Of the total sample, 51% were males, 65.7% were from public hospitals and 80.3% held a bachelor's degree. The mean score in the knowledge section was 9.7 (SD =1.7) out of 15; in the attitude section, it was 24.7 (SD = 4.8) out of 33; and in the practice section, it was 30.9 (SD = 3.5) out of 42. Nurses who reported previous related education scored higher on the knowledge section (mean = 10.7; SD = 1.4) than nurses who reported no previous related education (mean = 9.1; SD = 1.6; p < .001). However, no significant differences between these categories were found in relation to attitude and practice. The study demonstrated some lack of knowledge and unsafe practices regarding physical restraint in ICUs in Jordan. It suggests improving nurses' knowledge, attitude and practices through in-service education on best practice for physical restraint, developing policies/guidelines and providing adequate staff and equipment to maintain patient safety and prevent complications. Conducting education programmes on physical restraint for ICU nurses and providing other preventive strategies are important in improving nurses' knowledge, attitude and practice.

Effectiveness of Multifactorial Intervention on Observance of Physical Restraint Standards of the Patients Hospitalized in Intensive Care Units

Background: One of the important duties of nurses is to protect patients against any injuries. In most cases, physical restraint is applied as one of the immunity tools. In cases that other actions are not possible, physical restraint seems to be one of the acceptable interventions to protect patients or personnel of the unit. Objectives: The current study aimed to assess the effectiveness of multifactorial intervention on observance of physical restraint standards of patients hospitalized in intensive care units. Patients and Methods: In this clinical trial study, 240 patients under physical restraint and hospitalized in intensive care units of Hazrat Rasool Akram hospital were studied in two control and intervention groups with convenience sampling. Observance of the physical restraint standards was first recorded with observational checklist. Then, the multifactorial intervention (education through pamphlet, installation of poster in the unit and physical restraint datasheet) was executed for one month. After that, observance of standards was recorded and compared with that of the control group. The collected data were analyzed using SPSS v.16 software with independent t-test and Chi-square test. Results: The findings showed that observance of physical restraint standards in the control group was undesirable in more than half of the patients (56.7%) and relatively desirable in the intervention group for the majority of the patients (73.3%). Result of independent t-test showed statistically significant difference in observance of standards between the control and intervention groups (P value < 0.001). Conclusions: Considering the obtained results, multifactor intervention increased the observance rate of physical restraint standards for patients hospitalized in intensive care units. As a result, it is suggested to use multifactor intervention (education to personnel, recording restraint and installing poster) to improve immunity of patients and reduce the side effects of physical restraint in intensive care units.

Use of physical restraints in Dutch intensive care units: a prospective multicenter study.

Increasing evidence indicates that harmful effects are associated with the use of physical restraint. To characterize the use of physical restraint in intensive care units. Prevalence, adherence to protocols, and correlates of the use of physical restraint were determined. For comparisons between ICUs, adjustments were made for differences in patients' characteristics. A prospective, cross-sectional, observational multicenter study with a representative sample (n = 25) of all Dutch intensive care units, ranging from local hospitals to academic centers. Each unit was visited twice, and all 379 patients admitted during these visits were included and were examined for use of physical restraint. Physical restraint was used in 23% of all patients (range, 0%-56% for different units). Of all 346 nurses interviewed, 31% reported using a protocol when applying physical restraint. When corrections were made for clustering within units, the risk for use of physical restraint was increased in patients with delirium or coma, in patients who could not communicate verbally, and in patients receiving psychoactive or sedative medications. Sex, severity of illness, and nurse to patient ratio were not independently related to use of physical restraint. In 11 units (44%), use of physical restraint was more frequent than expected on the basis of patients' characteristics, although this finding was not significant. Physical restraint is frequently used in Dutch intensive care units. The differences in frequency between units suggest that opportunities exist to limit the use of physical restraint.

Restricciones físicas en UCI: su utilización y percepción de pacientes y familiares

IntroductionThe use of physical restraints in Intensive Care Units (ICU) is common although little is known about patients’ and relatives’ perceptions of this use. Objectives1) To analyze the prevalence and use of physical restraints in a general adult ICU; 2) to know the perceptions of patients who experienced use of physical restraints and; 3) to know the perceptions of relatives of patients who used physical restraints. MethodsThis descriptive study, which used both quantitative and qualitative methods, was carried out in an adult ICU. For the first objective, all the patients (101) who had used any kind of physical restraint were analysed. For the second and third objectives, 30 patients and 30 relatives were interviewed using the guidelines of Strumpf & Evans as modified by Hardin (1993). All interviews were recorded, fully transcribed and then submitted to a language content analysis using the method of Hsieh & Shannon. ResultsThe only physical restraint used was the wrist restraint with a prevalence of 43.47%. Seventy-two percent of patients wore the restraint ≤12h and 28%>12h. Analysis of the patient interviews revealed 4 main themes: acceptance of the restraint conditioned by beliefs and information provided; feelings and sensations caused by the use of the restraint; alternatives proposed and future repercussions. Three themes emerged from the interviews with relatives: impressions caused by the use of the restrictions; reasons for accepting or rejecting them; alternatives to the use of restraints. ConclusionsMost patients used physical restraints for a short period of time and only the wrist restraint was used. Patients using physical restraints and their relatives expressed a wide range of feelings and sensations, with no negative future repercussions. In general, they agreed with the use of restraints although more precise information would lead to greater acceptance.

Restraints in intensive care units—A mixed method study

The use of mechanical restraints is a controversial practice internationally but is common in South African Intensive Care Units (ICUs). Their use was studied in the ICUs of an academic, public hospital in Johannesburg, South Africa. Quantitative data were collected over two months by means of a checklist and analysed by means of descriptive statistics. The patients' length of stay, type of restraint used and duration thereof, the daily nurse patient ratios, as well as information regarding sedation and analgesia were detailed. Individual interviews with twenty medical and nursing ICU clinicians elicited their stated rationale for restraint, their experiences and perceptions of the practice and recommendations for restraint. Of a total of 219 patients in the three ICUs, 106 (48.4%) were restrained. The average number of days restrained was nine with a range of days from 1 to 53 (in one case only). In only six cases were restraints other than wrist ties used. Forty seven of the restrained patients had sedation and analgesic medication prescribed and 59 not. All participants conceded a place for physical restraint in the ICU, primarily to ensure the safety of patients but were divided as to the reason for restraining patients and disputed the benefits of restraint. Poor communication between the team, patients and families and diminished collaboration within the multi-disciplinary team emerged as central concepts in this study and influenced care decisions and practises regarding the use of mechanical restraints in the clinical area.